Group Medical Visits: Introducing the "Group Inclusion Effect" and Key Principles for Maximization

Food as medicine, community as medicine: Mental health effects of a social care intervention

OBJECTIVE

To assess mental health related outcomes of Recipe4Health, a multisectoral social care partnership implementing produce prescriptions with or without group medical visits (GMVs).

STUDY SETTING AND DESIGN

Recipe4Health was implemented at five community health centers from 2020 to 2023. Primary care teams referred patients with food insecurity and/or nutrition-sensitive chronic conditions (e.g., diabetes, depression) to 16 weeks of Food Farmacy (produce prescriptions) with the option of GMV participation. We used a convergent mixed-methods design including survey and interview data.

DATA SOURCES AND ANALYTIC SAMPLE

We conducted (1) participant surveys pre- and post-intervention and (2) semi-structured interviews with Recipe4Health participants and partner organization staff. Linear mixed effects models examined changes in mental health and related outcomes. Interviews were analyzed using codebook thematic analysis.

PRINCIPAL FINDINGS

Program participants were middle-aged, primarily women, and from diverse racial/ethnic backgrounds (majority Latine and Black). At baseline, moderate or severe depression and/or anxiety symptoms were reported by 77/188 (41%) of Food Farmacy-only participants, and 113/284 (40%) of Food Farmacy +GMV participants. Among Food Farmacy-only participants, post-intervention depression and anxiety symptoms significantly improved only among those who did not have baseline depression/anxiety (PHQ9: -1.7 [95% CI: -2.8, -0.6]; GAD7: -1.8 [95% CI: -2.9, -0.8]). Among Food Farmacy +GMV participants, mental health symptoms improved regardless of baseline mental health; among those with baseline depression/anxiety: PHQ9: -2.4 (95% CI: -3.6, -1.2); GAD7: -0.9 (95% CI: -2.0, 0.1); among those without: PHQ9: -2.2 (95% CI: -3.2, -1.2); GAD7: -2.2 (95% CI: -3.1, -1.2). Improvements in social needs (food insecurity, loneliness) and health-related behaviors (fruit/vegetable intake, physical activity) varied by intervention arm and baseline depression/anxiety symptom level. In interviews, staff and patients endorsed produce prescriptions for improving nutrition and food insecurity, and GMVs for increasing social support.

CONCLUSION

Social care interventions providing vegetables and fruit, with or without group medical visits, may concurrently address mental health symptoms and social needs.

Social Capital and Cultural Health Capital in Primary Care: The Case of Group Medical Visits

This article focuses on an empirical setting that upends the clinician-patient dyadic norm: group medical visits (GMVs), in which multiple patients gather in the same space for medical care, health education and peer support. Our grounded theory analysis draws on participant observation and interviews (N = 53) with patients and staff of GMVs at four safety-net healthcare organisations in the United States. We delineate (1) how group medical visits provide health-focused social networks that facilitate the mobilisation of social capital, (2) how the organisationally embedded relationships that comprise group visits are made possible through extended time that is part of the GMV field and (3) how clinicians have opportunities rarely found in other settings to learn from patients, using knowledge accrued from GMV networks to advance their own skills, thereby converting social capital into provider cultural health capital. GMVs provide a rich empirical site for understanding the ways in which organisational arrangements can shape opportunities for patients and clinicians to cultivate and mobilise social capital and cultural health capital, and in doing so, materially shift experiences of receiving and providing healthcare.

Mindfulness-Based Group Medical Visits: Strategies to Improve Equitable Access and Inclusion for Diverse Patients in Cancer Treatment

Background

Mindfulness-based interventions (MBIs) are supported by clinical practice guidelines as effective non-pharmacologic interventions for common symptoms experienced by cancer patients, including anxiety, depression, and fatigue. However, the evidence predominately derives from White breast cancer survivors. Racial and ethnic minority patients have less access to integrative oncology care and worse cancer outcomes. To address these gaps, we designed and piloted a series of mindfulness-based group medical visits (MB-GMVs), embedded into comprehensive cancer care, for racially and ethnically diverse patients in cancer treatment.

Methods

As a quality improvement project, we launched a telehealth MB-GMV series for patients undergoing cancer treatment, delivered as four weekly 2-hour visits billable to insurance. Content was concordant with evidence-based guidelines and established MBIs and adapted to improve cultural relevance and fit (eg, access-centered, trauma-informed, with inclusive communication practices). Program structure was adapted to address barriers to participation, with ≥50% slots per series reserved for racial and ethnic minority patients. Intake surveys incorporated a demographic questionnaire and symptom assessments. Evaluations were sent following the visits.

Results

In our first ten cohorts (n = 78), 80% of referred patients enrolled. Participants were: 22% Asian, 14% Black, 17% Latino, 45% non-Latino White; 65% female; with a median age of 54 years (range 27-79); and 80% had metastatic cancer. Common baseline symptoms included lack of energy, difficulty sleeping, and worrying. Most patients (90%) attended ≥3 visits. On final evaluations, 87% patients rated the series as "excellent"; 81% "strongly agreed" that they liked the GMV format; and 92% would "definitely" recommend the series to others. Qualitative themes included empowerment and connectedness.

Conclusion

Telehealth GMVs are a feasible, acceptable, and financially sustainable model for increasing access to MBIs. Diverse patients in active cancer treatment were able to participate and reported high levels of satisfaction with this series that was tailored to center health equity and inclusion.

Mindfulness-Based Group Medical Visits in Primary Care for Stress and Anxiety: An Observational Study

Background: The prevalence of anxiety disorders in primary care is 20%, with 41% of these patients reporting no current treatment. Patients with anxiety are also more likely to have comorbidities with other medical and/or psychiatric conditions, increasing medical costs. Integrating mindfulness-based interventions (MBIs) into a group medical visit (GMV) format has been successfully used to manage pain, but limited literature is available on the effectiveness of these visit formats for patients with stress and anxiety. Methods: Ninety-two adult patients with self-reported stress and/or anxiety were recruited from three university outpatient primary care clinics between 2016 and 2019. Participants attended at least 4 of 6 weekly GMVs focused on MBIs. Change in heart rate, blood pressure, Generalized Anxiety Disorder-7 (GAD-7) score, and 9 item Patient Health Questionnaire (PHQ-9) score from the first to last visit were evaluated using mixed effect linear regression models. Results: Both GAD-7 (estimated change: -5.1; 95% confidence interval [CI]: -6.4 to -3.7) and PHQ-9 (estimated change: -3.3; 95% CI: -4.3 to -2.2) scores significantly decreased from the first to last visit. These reductions were independent of age, sex, and number of visits attended. No significant changes in heart rate or blood pressure were found. Conclusions: Significant reductions in anxiety and depression in primary care patients were observed after a 6-week standardized mindfulness based GMV. Intergroup variability was not significant indicating that the intervention is reproducible over time and across providers. Future randomized controlled trials with appropriate controls will better evaluate which components of the intervention account for findings.

Qualitative Needs Assessment for the Development of Chronic Pain Group Medical Visits

Group medical visits (GMVs) for patients with chronic pain are becoming more accessible and have been shown to be successful in furthering patient education on multidisciplinary, nonopioid interventions. Unfortunately, evidence suggests that many group visit models lack sustainability due to recruitment issues and retention rates. Additionally, most of the studies surrounding GMVs are located in primarily urban health centers, potentially limiting their generalizability. This study aims to identify patient interest in and barriers to GMVs for chronic pain and to explore how chronic pain impacts daily lives for GMV content optimization in a nonurban population. Nineteen participants age 18 to 65 years participated in semistructured phone interviews to generate a thematic analysis. Participants received their care from family practitioners at a suburban multiclinic academic medical group and were being prescribed at least 50 morphine milligram equivalents (MME) at the time of recruitment. Analysis generated two themes: (1) Participants expressed specific interest in GMVs with few barriers identified, and (2) Pain has a negative impact on mental health and most aspects daily life, creating a foundation for discussion in GMVs. Findings support significant patient interest in group medical visits for chronic pain, but careful planning is necessary to address patient needs, expectations, and barriers in order to ensure GMV sustainability.